What have you been reading, hearing or TV viewing that has provoked some feelings of comfort or concern about what is happening in the world of medicine, medical care, treatment or science? Ethics is all about doing the right thing. Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior?
Write about them here.. and I will too! ..Maurice (DoktorMo@aol.com)

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Tuesday, May 28, 2013

"Good People Doing Bad Things for Good Reasons": Revision

The following original article which I wrote and was published today at thebioethics.net websiteis reproduced here with permission. ..Maurice

05/28/2013

What is ethical or not is often in the eye of the beholder. That is why often the ethics of decisions or acts that we deal with in medicine is established through the process of consensus. And I don’t necessarily mean consensus by only scholars, lawyers or ethicists or even physicians. I think in ethical consensus the many voices of society should be included. I think that an understanding of reason for the divergent views that may occur in ethical analysis can be expressed by what Marcia Angell, former editor-in-chief of the New England Journal of Medicine has said in the past. Perhaps you have already have heard it.“Ethical violations are usually not a case of bad people doing bad things for no good reason, it is usually the case of good people doing bad things for good reasons.” If it were bad people, bad things and bad reasons, there would be no ethical conflicts. The question is whether the acts of those good people carried out for those good reasons best meet the principles of ethics for that particular issue.Many times in clinical ethics, we find that all of the stakeholders of an issue have meritorious reasons to base their suggested actions. There also may be a meeting of an ethical principle for each action so that there is no strictly unethical violation. The problem arises when one action is inconsistent with another action and we have to decide which act and its ethics trumps another. But trumping may mean that some stakeholders may lose. Therefore, those of us who perform the responsibilities of the hospital ethics committee must remember that we are dealing with good people who have good reasons and perhaps their intended actions are not even that bad except in light of the context of the issue.

Three members of a hospital ethics committee met with 4 family members and two physicians of the patient to come to a decision about the patient’s further management. The patient, a 67- year-old diabetic male who had been a heavy smoker for most of his life, three weeks earlier had suffered a massive stroke which left him unconscious and unresponsive but able to breathe. Supplemental oxygen by nasal catheter had to be replaced by continuous ventilator breathing support within the Intensive Care Unit when after a week bilateral pneumonia developed and adequate spontaneous breathing ceased. His course was further complicated by signs of progressive renal failure and gastro-intestinal bleeding of unknown cause, which was significant enough to require repeated blood transfusions to maintain a minimally satisfactory blood count. The patient’s mental state remained unchanged.

The attending physician and neurologist presented to the family and the ethics committee a conclusion to terminate energetic treatment because the patient’s condition was progressively worsening despite intensive medical management, the patient would be unable to tolerate exploratory surgery for the bleeding and the neurologic prognosis was that significant recovery was unlikely. The ethics committee reminded the meeting that the repeated blood use was utilizing a particularly scarce resource. The son and two daughters agreed with the physicians’ conclusion but the wife who was the legal surrogate stated that she was told by the nursing staff, confirmed by the physician, that the patient had begun triggering the ventilator and that she felt that this was a good sign and that her husband would have wanted treatments to continue.

One of the tools the ethics committee has in this case is compromise. Sometimes compromise mitigates the conflict if even only temporarily. Though it may be only a band-aid in making an ethical solution, it often permits time to get the parties together on a final decision. If, as an example, the issue is end-of-life decision-making and family members are in conflict as to whether enough time on treatment has elapsed to be assured that the patient will not recover, a compromise can be often reached.

In the case presented, at the suggestion of the ethics committee members, the family and physicians agreed to seven more days of current management and then meeting again to re-evaluate the situation and if there was no improvement to then agreed to provide solely comfort care rather than the current attempts to cure. While the ethics committee agreed with the physicians’ initial conclusions along with that of the children, the committee recognized that the wife, as the surrogate, had some basis for her initial rejection and that compromise with the wife was appropriate.

Those of us “doing ethics” should always temper our dogmatic views, if we carry them, to realize that generally we are dealing with good people and their good reasons. And the “bad” things they may want to do is often just “relatively bad.”.

12 Comments:

“Ethical violations are usually not a case of bad people doing bad things for no good reason, it is usually the case of good people doing bad things for good reasons.” Can we quantify the word "usually" in that sentence, or even gather enough evidence to make a value judgment? It's not just a question of "people." It's also a question of the "system" and the constraints the system may be putting on the these people. How often do caregivers violate ethical principles because it's convenient for the system, or convenient for themselves? I'm not talking necessarily about life and death situations, but everyday, one-on-one, patient-centered care situations. I refer you to "The Lucifer Effect: Understanding How Good People Turn Evil" by Philip Zimbardo. Now, be clear -- I'm not calling caregivers "evil" or saying these ethical violations are necessarily "evil" -- but I think what Zimbardo has to say about this topic directly connects to what you're asking, Maurice. Sometimes it's difficult to find that line where actual evil begins. Some quotes from the book: "My appreciation of the power residing in systems started with an awareness of how institutions create mechanisms that translate ideology -- say, the causes of evil -- into operating procedures..." (p.9). So -- to what extent are health care systems creating the context for caregivers to first try to please the system, or rationalize why what they're doing is really good for the patient when it's actually good for themselves or the system or both? "In other words, my focus has widened considerably through a fuller appreciation of the ways in which situational conditions are created and shaped by higher-order factors -- system of power. Systems, not just dispositions and situations, must be taken into account in order to understand complex behavior patterns." (p. 10) "Aberrant, illegal, or immoral behavior by individuals in service professions, such as policemen, corrections officiers, and soldiers, is typically labeled the misdeeds of 'a few bad apples.' The implication is that they area a rare exception and must be set on one side of the impermeable line between evil and good, with the majority of good apples set on the other side. But who is making the distinction? Usually it's the guardians of the system, who want to isolate the problem in order to deflect attention and blame away from those at the top who may be responsible for creating untenable working conditions or for a lack of oversight or supervision. Again the bad apple-dispositional view ignores the apple barrel and its potentially corrupting situational impact on those within it." How about a system analysis that focuses on the barrel makers, those with who actually design and make the barrels? As Zimbardo says, systems create hierarchies of dominance with influence and communication going down, rarely up -- the line." The medical industrial complex is as powerful in its own right as is the military industrial complex. We also now have an educational industrial complex. I'm certainly not negating individual responsibility and people's ethical obligation to do right -- but these systems too often drive the ethical decisions and too often in favor of protecting the existence of the systems themselves. In our culture, we underestimate the power of authority figures, and the power of group think, and how easy it is for the human mind to rationalize doing bad things for good reasons.

First, we have to consider another possibility not presented in my thread: "Good people doing bad things for bad reasons". First, establishing what defines the person or persons as "good" or "bad" should made. In ethics, I think we can call a person "bad" if he or she or they show total disregard of the unethical consequences of their actions and, in face of the consequences, fail to attempt to learn, understand and attempt to mitigate the results but continue their actions. The persons not defined as "bad" can be otherwise, relative to the particular action, considered, for the time being, as "good" but beginning to recognize their ethical errors.

Institutions and systems should still be considered made up by individual persons and each plays their own role in the establishing of an ethical institution or system regardless of their position in the system. Their individual decisions contribute in each particular way to the decision of the whole. And each person in the whole can be labeled "good" or "bad" depending upon each response. If they make no attempt to do an ethical "good" and, within their individual capabilities, make no attempt to change the institution or system, each can lose the label of "good" if the institution continues in its "bad" ways. I can understand the burdens of "standing up" against the system policies but being part of the system, each individual has the responsibility and must work for being that "good apple".

An institution or system can be looked upon as unethical if the direction of the system is one of ignoring those for whom the system has primary ethical responsibility. In the case of hospitals, I think it is pretty clear that the primary responsibility, the reason the hospital was created, is not for the administrators, employees or the hospital investors but for the patients themselves as individuals. In the case of pharmaceutical companies, their ethical decisions should be also guided by to whom they are primarily responsible. It is my opinion that it is also the patient and not the stockholders. That is why the pharmaceutical company that developed and is selling an effective leukemia treating drug should not be raising the yearly price of the drug three times its original price to a exorbitant level limiting its availability to the needy cancer patient when the company is experiencing an increased population of patients requiring the drug and having long past recouped all the expenses for the development of the drug.(BloodJournal.Hematology, April 25,2013.) Those who are aware of the behavior of the company should take their ethical responsibilities.

My point is that being a "whistle-blower" regarding unethical behavior or policy in an institution or a physician or nurse who behaves with humanism to patients despite being in a system which because of alleged unmanageable factors lacks that attention represents that all individuals in an institution or system have the potential for being that "good" individual. In conclusion, I disagree that ethical behavior expression of members within an institution or system can be excused by being only an "apple in the barrel". ..Maurice.

I would toss another thought out, "Good people doing bad things for questionable reasons". Forgeting the outliers, I do believe that most people go into medicine for admirable reasons. For the most part they continue to operate in the system under that as well, doing far more good than harm and doing so with passion and best intent. However, where I see the bad come in is where providers, carry forward an agenda that is sometimes harmful, in our discussion, violating, ignoring, or at best downplaying modesty concerns of patients. If you look at the various discussions on numerous forums, it is evident in the conflict in how modesty is addressed when the provider is the patient. I think providers work to convince themselves that their actions are for the best interest of the patient and therefore are good reasons. They convince themselves proper behavior by them addresses lost modesty UNTIL they are the patient. Justifying requiring special accomodation for providers comes in numerous forms, it is different because we know eachother, it is different because I work here, etc. When one looks at the outrage on allnurses about having to practice bed baths and wear a bathing suit compared to what they subject patients to and especially patients in a teaching hospital...it is clear there is justification happening to make the ethical conflict...not truely a conflict. I wonder if there isn't an ethical issue for many, but the justification takes away the this isn't for my or the facilities benefit, it is for the patient and it is different when I am the patient. It makes the issue grey, or questionable rather than black or white, right or wrong...don

Zimbardo gives us what I consider a good working, psychological definition of evil. He writes: "Evil consists in intentionally behaving in ways that harm, abuse, demean, dehumanize, or destroy innocent others – or using one’s authority and systemic power to encourage or permit others to do so on our behalf." Zimbardo also quotes Iriving Sarnoff as writing – Evil is knowing better but doing worse. That's a pretty broad definition, and covers hospital situations, esp. with words like "demean" and "dehumanize." It also covers those who encourage or permit others. A point that Zimbardo makes in his book is that history shows that good people do stand up to evil, face it down, sometimes stop it or at least bring it to the world's attention. Of course, this is done at a high price, often death and great sacrifice. I'll also point the work of philosopher Albert O. Hirschman who died late last year. Some of his books include "Exit, Voice, and Loyalty" (1970) about ways to respond to unjust or frustrating or unethical organizations or relationships (which directly applies to this discussion); "The Passions and the Interests" (1977), about defending capitalism and commercial interactions; "Shifting Involvements" (1982), about the attractions of political vs. personal life and how they interact; and "The Rhetoric of Reaction" (1991), which identifies typical objections to proposals for reform (which again involves this discussion. In "Exit, Voice, and Loyalty," he gives three basic responses to unjust organizations and relationships. You can leave or "exit." You can "complain." If your loyal you won't exit or complain. Of course, even if your loyal -- if you're intimidated or afraid you won't complain -- and if you need the job you may neither nor complain. In the "Rhetoric of Reaction," Hirschman covers three main standard objections to reform. "Perversion" -- The reform will make the problem even worse. "Futility" -- The reform will do nothing to solve the problem. "Jeopardy" -- The reform will endanger some hard-won social gain. I think these arguments apply directly to the objects we get to reforming the medical culture's attitudes and behavior toward patient modesty and gender neutrality. As to Don's points -- I think you might be surprised that many if not most medical professionals who end up in the hospital don't get special treatment, esp. regarding modesty. They may wake up to the issue by actually experiencing it, but most of them will not speak up for many reasons. Some are embarrassed to confront their peers, or embarrassed to admit they have this issue in a culture that will see them as an outlier; or afraid that, if they do complain, it may not only affect their treatment but even more threatening, affect their relationship with the system when the return to work. I'm not suggesting that they are never treated specially regarding their modesty -- but the fact they are most often not demonstrates how embedded the gender neutral and obtuse behaviors are regarding modesty in many medical systems.

I want to explain how I can include myself as an "individual within the medical system" and should be recognized as ethically "good" despite the ethical issues of patient modesty and dealing with those issues by the medical system.

I am a "good" person within the system not only because of my attention to the apparent needs of the patients in my experience in private practice but also for the following major reason. When I started this thread based on the solitary article "Naked" in the New England Journal of Medicine in 2005, the flow of input from visitors began, the nature and content of which certainly was derogatory toward the medical profession and the system of medicine. Now, I became an ethical "good" member of the system after reading a number of visitor responses by NOT terminating the Patient Modesty thread which is something I had the potential to do if I believed that these negative comments were exaggerated, degrading and inappropriate descriptions of the professional work and personal behavior of healthcare providers. I continued the thread because I was convinced that there was a real possibility of a defect in the medical system which I couldn't simply exclude by the comments I was receiving. In fact, not only did I continue the thread, I have tried to encourage advocacy by those concerned to change the medical system.

This explanation by me is not to "pat myself on the back" that I am an ethical "good" person in this regard but to emphasize that with regard to defects in the system, the system is comprised of individual participants and each are responsible for the behaviors of the system and must individually demonstrate that they are attending to those defects to be considered "good" with regard to an ethical issue. I think that the "apple barrel" is created from the "bottom up" and not the "top down" and so as members of the system we should all responsible for the system's consequences.

Finally, as a patient when hospitalized, I experienced no significant physical modesty issues despite others might consider such issues did occur. The reason: I always have set whatever modesty concerns I have well below the value of obtaining a beneficial medical/surgical conclusion. ..Maurice.

"I think that the "apple barrel" is created from the "bottom up" and not the "top down" and so as members of the system we should all responsible for the system's consequences."

I agree that we all should be responsible, and I'm not dismissing individual responsibility. But I believe you're underestimating the power of authority, systems and culture. The apple barrel is first created by the people who design and build it. Then by the people who create the policies and run it. Its essence is determined by such factors as the kind of apples that are put in, their condition, their quantity, and how they are packed. This analogy isn't perfect -- because "apples" can't change their condition, people can. But the psychology of how people behave is complex and, as we know from history, human beings are often perfectly willing to put up with the deplorable conditions they know rather than challenging them and changing to conditions, better or worse, that they don't know. The unknown is often more frightening that any reality, good or bad.

But, Doug, regardless how the institution was started and by whom, the participants must bear the ethical responsibility for consequences of their activities be it administrator, physician or technician regardless of the "condition of the barrel". Tragic examples abound in medicine such as, of course the Nazi experiments, Tuskegee syphilis study, Willowbrook hepatitis children study and the Guatemala VD studies. In our recent years, where was the ethical responsibilities and reactions shown by the physicians who were participating in the U.S. governmental interrogation of prisoners using torture techniques?Yes, there may be only a few who develop a particular system but often there are many more who carry out the system's practices and they all bear ethical responsibility for their actions (or inaction) in the system and the forming or shaping of the "barrel" and the end-result. ..Maurice.

Maurice I don't disagree that the apples need to step up and take responsibility. But the facts of history demonstrate that they most often don't. Only a a few, but thank God those few do because they demonstrate to us that we are capable of doing what is right. Most people will obey authority, esp. uniformed authority. Especially uniformed authority whose identity is hidden by masks or other clothing. Most people will defer to that authority, rationalizing that it's not their responsibility or that the authority knews more than they do. Or, they'll convince themselves that that kind of decision is above their pay level and responsibility. Most people will not risk their jobs to turn in those who don't follow ethical rules or guidelines. I'm not talking about what "should" happen. I'm talking about what most often "does" happen. And I think this behavior is getting worse in our culture not better. We're an "individualist" culture. Our myths evolve around rugged individualism. We perhaps put too much emphasis on the power of individuals once they get caught up in massive systems that care for little but their own survival. Still, I agree with you that the apples must stand up and take on that responsibility.

Doug, but now turning to the views presented regarding patient modesty issues in the long running "Patient Modesty" thread. wouldn't you think that it would be unfair and inconsistent with your view of organizations and systems to apply so much blame on the behavior of individual physician, nurses, other nursing staff and technicians if the primary molders of behaviors within the hospitals and clinics and the medical system itself is not the physicians and staff but those who are executives of the institutions or the ones who set the standards for professional care. And then there are the factors within the system which have developed which cannot be easily changed by recrimination towards the providers such as the current imbalance of genders of nursing staff and techs in the various specialties or the time available to attend to individual patients because of limitations set within the system by others or simple patient to provider ratios.

Not that those who write to the Patient Modesty thread about the direct healthcare providers should be ignored but perhaps those patients should also acknowledge that though the individual providers should be aware and concerned and try to correct about these issues in the system, based on your analysis, they, the providers, shouldn't be blamed as they have been. ..Maurice

Maurice -- We're not communicating. You write -- "based on your analysis, they, the providers, shouldn't be blamed as they have been." Reread my texts. I'm not saying that individuals should not share blame. Of course they should. But "tones" are set by those in charge. "Cultures" are created. "Underground curriculums" exist. Certainly, individuals can decided to be "loyal," or "complain" or "exit" as I quoted from Hirschmann's book. You seem to want to simplify a complex area. It's not who's to blame. In a system that ignores ethics, a corrupt system, -- all in the system who know that wrongs are being committed and continue to commit those wrongs, all are to blame. But there are degrees of blame, too. Still, I make no excuses for nurses or doctors who know parts of the system are unethical and continue to go along with the it. Huge systems take on personalities and momentum and begin to drive and use individuals for their own purposes. After all, Maurice, hasn't the Supreme Court ruled that corporations are individuals. Strange and interesting, isn't? You, apparently, have more faith in human beings than I do. There are some saints and poets out there, but not many. I contend that you can take most good, ethical, moral, human beings, put them in worst-case-scenario situations, and they'll be willing to commit the most atrocious acts. The ones most likely to behave like this will be those who think that they could absolutely not commit such acts. Most people in our celebrity obsessed (fame and fortune) culture won't risk their reputations, their jobs, their houses and cars, their safe lifestyles -- to go against the current, against the grain, against the powers that be. They just won't. I hope I'm wrong. I really do. But I read history and observe what's going on in world. And that's how I perceive it. As to the factors that "can't" be "easily changed," if have little sympathy for the powers that could make the changes. And what if those factors involve patient respect and dignity? "Easily changed?" No worthwhile change is easy. It's a question if will as much as anything else. "Can't" be changed. I don't believe it. If we only tried to change factors that were easy, we'd be consistently waisting our time twiddling our thumbs.

Doug, I am glad to see that you agree with my initial expression of responsibility for the condition of the system is the contribution of "all the apples in the barrel". nstitutions and systems should still be considered made up by individual persons and each plays their own role in the establishing of an ethical institution or system regardless of their position in the system. Their individual decisions contribute in each particular way to the decision of the whole. And each person in the whole can be labeled "good" or "bad" depending upon each response. If they make no attempt to do an ethical "good" and, within their individual capabilities, make no attempt to change the institution or system, each can lose the label of "good" if the institution continues in its "bad" ways. I can understand the burdens of "standing up" against the system policies but being part of the system, each individual has the responsibility and must work for being that "good apple".

Beyond how the "barrel" was constructed and maintained, one sick "apple" can affect the other "apples" and therefore the value of the "barrel" itself.

Doug, again thanks for providing us considerable "food for thought" even food as simple as an apple. ..Maurice.

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